ARRA and the HIM Workforce

By Genna Rollins

The success of health IT will hinge on how well it is planned and managed. Provisions in the stimulus bill that promote professional support and fund training offer exceptional opportunities to HIM programs, individuals, and the profession.

For years AHIMA and collaborating organizations including the American Medical Informatics Association have broadcast the need for an expanded and more diversely trained health information management and technology workforce. A proliferation of health IT will require a simultaneous increase in professionals trained to plan, implement, and manage it.

AHIMA, AMIA, and other professional associations also have called for a systematic plan to train other healthcare workers to use IT tools to perform their jobs in an environment where electronic health records will be the order of the day.

Now that need is being recognized and addressed through substantial federal investment in healthcare workforce training that is part of the American Recovery and Reinvestment Act (ARRA).

“In establishing ubiquitous, robust [health] IT across the country, there are not nearly enough people doing this work to cover the nation, so it’s incredibly important to work on training,” says David Hunt, MD, chief medical officer of the Office of the National Coordinator for Health Information Technology. ONC, housed within the Department of Health and Human Services, is responsible for implementing ARRA’s health IT provisions.

Several provisions of ARRA, which was signed into law February 2009, provide significant opportunities to expand HIM education and ensure that HIM professionals play a key role in building and maintaining successful health IT networks.

The two primary e-health sections of ARRA are division A, title XIII, better known as the Health Information Technology for Economic and Clinical Health (HITECH) Act, and division B, title IV, which provides for Medicare and Medicaid incentive reimbursements starting in 2011 to professionals and hospitals that are “meaningful users” of electronic health records.

These provisions are critical components in transforming the healthcare delivery system from one in which patient data resides in silos maintained by independent providers relying primarily on paper-based records to one characterized by interconnected networks of EHR users who actively exchange data to enhance patient care.

Key Workforce Provisions

HITECH includes approximately $2 billion in funding for loans, grants, and technical assistance to support health information exchange planning and development, EHR adoption, health IT extension programs, workforce training, and new technology research and development.

Many of the key workforce provisions are outlined in section 3016, which mandates the Health and Human Services secretary, in consultation with the director of the National Science Foundation, provide assistance to higher education institutions to expand or establish medical health informatics education programs, including certification, undergraduate, and master’s degree programs for both healthcare and IT students.

The types of activities eligible for support include developing and revising curricula, recruiting and retaining students, acquiring instructional equipment, and establishing or enhancing bridge programs between community colleges and universities. Priority funding will be given to existing programs and those that can be completed in six months. The emphasis is intended to speed newly trained workers into the workforce.

The eligible activities and funding priorities are tailor-made for the more than 180 associate degree programs currently accredited by the Commission on Accreditation for Health Informatics and Information Management Education, according to Brian Foley, MED, MHA, CPHQ, FACHE, provost of the Medical Education Campus of Northern Virginia Community College (NVCC) in Springfield.

“Community colleges can be force multipliers. They can create synergies and alignments between healthcare institutions, workforce boards, community organizations, and other educational providers,” he says. NVCC was instrumental in establishing NoVAHealthForce, a coalition of business, government, community, healthcare, and educational leaders collaborating to develop a sustainable strategy to address the Northern Virginia healthcare workforce shortage.

Foley views section 3016 as an excellent avenue to provide part-time, online, or short-duration health information training to key employees in physician offices, clinics, and other community-based providers that are operating primarily with paper records.

“We need to create a skill set that will provide a way for them to get the experience they need to work with the technology that will be coming to those sites, and that can help them move up the career ladder,” he says.

In 2008 AHIMA and AMIA jointly identified competencies in five core categories related to working with health IT (see sidebar [below]). That type of training would be crucial to helping the small group practices that predominate in US medicine and typically do not have a staff person dedicated to or with a background in IT.

Exactly how section 3016 will be implemented remains to be seen—ARRA delegated the details to ONC, which has yet to publish final program descriptions.

“Everyone’s sitting on pins and needles,” says Gerald Glandon, PhD, professor and chair of the department of health services administration at the University of Alabama at Birmingham. At press time, Hunt indicated that HITECH implementation plans were undergoing review by the Office of Management and Budget. “We’re at the stage where very soon we expect to make a public pronouncement about workforce training and how resources will be used in the community,” he said.

Regional Extension Centers

Another key HITECH provision authorizes ONC to create the National Health Information Technology Research Center and affiliated regional extension centers to assist providers in selecting and implementing certified EHRs. The research center will provide technical assistance and develop or recognize best practices, while the regional centers will be expected to disseminate best practices and participate “to the extent practicable” in health information exchanges.

The regional centers also will be tasked with integrating health IT into the initial and ongoing training of health professionals. Preference will be given to providers serving uninsured, underinsured, underserved, and special needs populations.

“We envision [the extension centers] to be the infantry on the ground, providing hands-on assistance and practical input in getting health information exchanges up to speed,” Hunt explains.

A key function of the regional centers will be to assist eligible providers, including independent physicians, dentists and nurse practitioners, among others, in becoming “meaningful users” of EHRs, a requirement of receiving incentive payments from Medicare and Medicaid under division B of ARRA.

A draft set of meaningful use requirements issued in June and revised in July and August included electronic prescribing capabilities, exchange of health information to improve the quality of care, and reporting on clinical quality measures. HHS will publish final requirements by the end of the year.

In a notice of funding opportunity released in August, ONC said it expected to begin selecting the first round of grant awardees for the regional centers in December. Additional awards will be made in two subsequent application cycles to be completed in 2010.

The incentives in the provision are front loaded, emphasizing acquisition and use of functioning EHRs early and again underscoring the need for immediate workforce training. Payments decrease with each year, and all incentives end in 2016.

At the same time, providers not considered meaningful EHR users will have their Medicare reimbursements cut by 1 percent starting in 2015, growing to 3 percent by 2017. If fewer than 75 percent of eligible healthcare professionals are meaningful users in 2018, HHS has the authority to cut reimbursements by another percentage point, up to a maximum of 5 percent.

“Doctors are goal oriented,” says Hunt, an MD. “They like the concept of EHRs, but they need for the implementation to be as easy as possible, and they’re asking, ‘Is there someone who can help me get set up?’ Workforce is the engine that can make this enterprise viable. Without hands-on folks to help implement IT, it’s really dead in the water.”

Another ARRA provision, section 3015, also enables HHS to award grants for demonstration programs integrating IT into clinical education for physicians, nurses, and other allied health professionals including HIM. That provision in particular is an opportunity for HIM programs that have already adapted their educational offerings to meet the changing needs of health information students, according to Glandon.

As an example, UAB-Birmingham converted its health informatics program from a traditional on-site model to a blended program with a mixture of on-site classes and distance learning. Experience gained from reshaping that program has Glandon thinking of an EHR “boot camp” to arm employees in clinics, physicians offices, and additional settings with the basic skills needed to oversee IT implementation and management.

“It could be aimed at people already in the workforce, like group practice managers, who often don’t have expertise in IT but are responsible for it. There could be different programs for different types of employees, and most of the content could be online,” he notes. AHIMA has taken a similar approach with its HIM Virtual Laboratory, which extends remote access to health IT software to HIM students in 175 college programs.

Department of Labor Funding

An important ARRA provision separate from HITECH involves $125 million available from the Department of Labor to train workers to pursue careers in healthcare. DOL’s Employment and Training Administration will oversee the funding process and expects to issue between 45 and 65 grants ranging from $2 to $5 million, with grant performance periods up to three years.

DOL’s request for proposals, published in July and due October 5, made special mention of the health IT field, which it defines as the “juncture of information management, medical practice, and the complex business of healthcare delivery.” The grants require “robust strategic partnerships” between at least one organization from each of three categories, including public workforce investment, public and private employers, and the education and training community.

Whereas workforce-related HITECH funding may be geared more toward workers with a broader set of health information skill requirements, the DOL provisions may offer more opportunities for people interested in specific skill sets like coding, according to Steve Collier, PhD, professor and director of the office of health professions education and workforce development at UAB-Birmingham.

“DOL programs typically are oriented at the associate and bachelor’s levels. My impression is that this provision will be addressing more coding and health information technician positions versus administrative types,” he observes. “They’re looking to get people in the workforce in the shortest amount of time.”

In the view of Glandon, both the DOL and HITECH provisions of ARRA also may open the doors for more collaboration between colleges and universities and the employer community.

“There are models now of employers paying for training for coders as an example,” he notes. “However, they’re squeezed right now in this economy and may be more reluctant to make those investments, especially when they’re not always able to capture gains because the employees jump to positions with other employers. So ARRA may be a way of subsidizing some of that training.”

Smaller amounts of workforce training funds may be available through other ARRA provisions, such as section 3014, which involves competitive grants to states and Indian tribes for the development of loan programs to facilitate widespread adoption of certified EHR technology.

Exactly what impact the various ARRA provisions ultimately will have on the health information workforce remains to be seen. “People are needed at a variety of levels, and in this new environment, it’s an open question as to how many new people will be needed; the percentage needed with master’s, bachelor’s, and associate-level training; [and] the percentage of managerial versus technical positions,” Glandon explains.

Collier sees differences in what ARRA will be supporting in the near term and what will be needed by the healthcare industry in the long term.

“In the short term I think there will be an expansion in the more technical positions like coders, but in the long-term, I’m not as optimistic about the demand for lower-level positions. I think there will be more need for information management positions and people with transferable skills,” he predicts. “Information management will grow in importance both in healthcare and outside of it.”

Genna Rollins (rollinswrites@verizon.net) is a freelance writer specializing in healthcare.